2021 BENEFITS ENROLLMENT GUIDE - THE UNIFIED GOVERNMENT OF ATHENS-CLARKE COUNTY
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THE UNIFIED GOVERNMENT OF ATHENS-CLARKE COUNTY 2021 BENEFITS ENROLLMENT GUIDE ENHANCING YOUR TOTAL REWARD AS A VALUABLE RESOURCE FOR OUR COMMUNITY
TABLE OF CONTENTS
A Message from Human Resources....................................................... 3
Open Enrollment Overview...................................................................... 4
THE UNIFIED POS Health Insurance Options................................................................ 6
GOVERNMENT OF
ATHENS-CLARKE CHS Health Insurance Options................................................................ 8
COUNTY Dental Plan............................................................................................. 10
Vision Plan..............................................................................................11
Access to BENEFITS Health Insurance Surcharges................................................................12
information at your
FINGERTIPS! Alight - Your FREE Healthcare Advocate...............................................13
Wellness Rewards - The Well................................................................. 14
Health Savings Account.........................................................................15
VISIT Flexible Spending Account.................................................................... 17
Critical Illness Insurance.......................................................................19
www.ACCGov.com
anytime to access ACCGov Group Accident Insurance.....................................................................20
Benefits and Wellness Income Protection Benefits................................................................... 21
program information. Insurance Premiums.............................................................................. 24
Group Accident and Critical Illness Insurance Premiums...................25
Life Insurance Premiums.......................................................................26
Other Valuable Benefits......................................................................... 27
How To....................................................................................................29
Online Enrollment Instructions.............................................................. 31
Contact Information...............................................................................34
The information in this material is intended to provide information only. It is not intended, and should not be taken, as a statement of legal
rights and responsibilities. While every effort has been made to ensure the accuracy of information included herein, discrepancies or errors are
possible. In the case of a discrepancy between this document and the Summary Plan Documents, ordinances, and policies governing benefits
adopted by the Mayor and Commission, the official plan documents, ordinances, and policies will prevail. The Summary Plan Documents,
ordinances, and policies on which the information in this document is based are subject to change or termination at any time by action of the
Mayor and Commission.
2
A MESSAGE FROM HUMAN RESOURCES
TO A GREAT YEAR AHEAD
Valued Employees,
We’re looking forward to another great year at the Unified Government of Athens-Clarke County (ACCGov). To express
our continued thanks for the important role you play on our team, we’re proud to again offer a quality benefits package
to help you stay healthy, feel secure, and enjoy a great work/life balance. Offering a competitive benefits package is
just one way we are able to reward our employees in a meaningful way.
Important Information about Open Enrollment:
If you can check one or more of any of the following, you must log in to the enrollment system and complete your
enrollment:
I am currently enrolled in, or plan to enroll in 2021, a Health Savings Account (HSA).
I am currently enrolled in, or plan to enroll in 2021, a Medical or Dependent Care Flexible Spending Account
(FSA).
I want to make ANY benefit changes for the 2021 plan year.
I would like to add or cancel one or more dependents from my plan(s) for the 2021 plan year.
I need to update my tobacco or spousal surcharge affidavit for the 2021 plan year.
If you can check all of the following, you do not have to complete Open Enrollment:
I do not wish to make any changes for the 2021 plan year, and
I will not contribute to a medical or dependent care FSA or HSA in 2021, and
I do not need to update my tobacco or spousal affidavits for the 2021 plan year.
Please be sure to verify the following information and update if needed:
Home address and telephone number. If you need to make a change, contact Benefits & Wellness to complete a
Status Change Form
Add your email address in the enrollment system
Life insurance beneficiaries: you may change in the enrollment system
Dates of birth and social security numbers for dependents on health insurance: this is required for IRS tax
reporting and must be correct. You may update in the enrollment system if needed.
Please note:
The Benefits & Wellness Division strives to provide prompt, efficient customer service. To better serve ACCGov
employees, we are introducing the Ask HR Benefits Help Desk. Log in to https://askhrbenefits.athens.local, select
your topic, & send us a message! There is also a “knowledgebase” with helpful information about your benefits. You
must be on an ACCGov network computer to access the Help Desk; your username & password are the same as your
network login.
Please review the information in this guide carefully to better understand your options. Open Enrollment is an
important time of year to decide what’s best for you and your family.
For full details about our plans, please refer to the Summary Plan Documents, which can be obtained from the Human
Resources Department or online at www.ACCGov.com/openenrollment
3
OPEN ENROLLMENT OVERVIEW
Key Terms
Before you review your options, please review some key terms to better understand your options.
Plan Year The period of time when your coverage is active (January 1–December 31).
The amount of money that’s paid for your health insurance every month. ACCGov pays
Premium
a portion of this amount, and you pay the rest.
The amount of money you need to pay out of pocket before your insurance
Deductible
begins contributing money to your health care costs.
A group of doctors, hospitals, labs, and other providers that your health
Network insurance contracts so you can make visits at a pre-negotiated (and often
discounted) rate.
A predetermined dollar amount you pay for visits to the doctor, prescriptions, and other
Copay
health care (as specified by your plan).
The percentage you pay for the cost of covered health care services after you’ve met
Coinsurance your deductible. For example, if the coinsurance under your plan is 20%, you would pay
20% of the cost of the service and your insurance would pay the remaining 80%.
In-Network Out-of-Pocket The cap on your out-of-pocket costs for the plan year. Once you’ve reached this
Maximum amount, your plan will cover 100% of your qualified medical expenses for the plan year.
¹Due to federal and state tax regulations, benefits provided to domestic partners are generally taxable and therefore deducted from your pay on
an after-tax basis. Additionally, any premium contributions made by ACCGov on behalf of your domestic partner are generally considered taxable
income to you. Contact the ACCGov Benefits Department if you believe your domestic partner is exempt from federal or state taxes.
Enrollment
You can enroll in or change your benefits each year during the annual open enrollment period for benefits effective
January 1–December 31, 2021. This is typically your once-a-year chance to choose or change coverage, unless you
experience a change in status.
4
OPEN ENROLLMENT OVERVIEW
Who is Eligible?
All full-time ACCGov employees are eligible for benefits on the first day of the Children include:
month after a full month of regular, full-time employment (unless expressly • Biological and adopted
stated otherwise under the description of the benefit). Full-time employees children (including those
and their eligible dependents can participate in the ACCGov benefit plan. placed in your home for
Eligible dependents include your: adoption)
• Spouse or domestic partner¹ • Stepchildren and domestic
partner’s children
• Child(ren) up to age 26
• Children for whom you
• Child(ren) of any age if he or she is incapable of self-support due to are responsible to provide
mental or physical disability health coverage under
¹Domestic partners may only be enrolled in health insurance, critical illness, whole life and a qualified medical child
group accident. support order
• Child of any age if chiefly
Dependent Eligibility dependent upon you for
When you enroll, you’ll be asked to verify your spouse’s or domestic partner’s support and maintenance
benefit status. We trust that all employees will provide accurate information. because of physical or
mental disability
You may be required to provide proof of eligibility for your dependents. • Other children for whom
Attempting to enroll an ineligible dependent could lead to discipline and the employee has
possible termination of employment. If your dependent becomes ineligible for permanent legal custody
coverage during the year, you must contact the Human Resources department
within 30 days. Failure to provide notification may lead to discipline and
possible termination of employment.
How To Enroll Note: Federal reporting
When and How Do I Enroll? requires we have every
Open Enrollment will be conducted October 1–October 31, 2020. You may dependent’s full name, date
go online from any computer to http://unum_accgov.bswift.com to complete of birth, gender, and Social
your enrollment. Please note: Your password has been reset to the last 4 of Security number. Please review
your SSN. all of these fields during the
What Information Do I Need to Enroll? enrollment process, as without
You need names, dates of birth and social security numbers of all dependents this information, ACCGov will
that you want to cover on your health, dental, vision and/or dependent life not be able to report coverage
insurance plan. You also need names, dates of birth and addresses for any for you and your dependents
life insurance beneficiaries. as required under the
Affordable Care Act.
Making Changes To Benefits
You can change your coverage during the year if you experience a qualifying
life event, such as marriage, divorce, birth, death, adoption, or loss of
coverage. The change must be reported to the Human Resources Department
within 30 days of the life event. (Declaring a Domestic Partner relationship
does not qualify as a life event.)
5
POS HEALTH PLAN
ACCGov’s health insurance plans are self-funded. This means the funds in the ACCGov budget for health insurance
actually pay the claims for those who utilize ACCGov’s health insurance plan. You can help keep insurance costs under
control by adopting healthy lifestyle habits, which naturally improve health and decrease claims cost. You can also
utilize the many resources ACCGov offers to be a wiser healthcare consumer.
Deductibles, Coinsurance &
In-Network Plan Benefits Out-of-Network Plan Benefits
Maximums
Calendar Year Deductible, by plan POS Conventional POS Conventional
-Individual $1,000 $2,000
-Family $2,000 $4,000
One deductible for employee, one for spouse,
one for all eligible children
Plan pays 80% after deductible Plan pays 60% after deductible
Coinsurance
Member pays 20% after deductible Member pays 40% after deductible
Lifetime Maximum Benefit Unlimited Unlimited
Out-of-Pocket Calendar Year Maximum* POS Conventional POS Conventional
-Individual Includes deductible Includes deductible
-Family $4,500 $9,000
$9,000 $18,000
All family members covered under the Plan contribute toward the total Family deductible and Out-of-pocket maximum. The most any one family
member contributes is the Individual amount. Once the Family amount is satisfied, there is no further accumulation for any family members. Non-
covered items do not apply to the out-of-pocket maximums. Deductible and Out-of-pocket amounts are accumulated separately for in-network
and out-of-network services.
POSC Plan Services In-Network Plan Benefits Out-of-Network Plan Benefits
Office Visits: Preventive Care
Well-child care and immunizations,
Plan pays 60% after deductible
Annual wellness exam Plan pays 100%
Deductible waived through
Annual GYN exam Not subject to deductible
age 5 for Well-child care and
Annual mammogram
immunization visits
Prostate screening
Illness or Injury
Physician office visit $30 copay Plan pays 60% after deductible
Includes lab, radiology, and office surgery
Specialist office visit and 2nd surgical
$60 copay Plan pays 60% after deductible
opinion
Maternity services
$100 copay Plan pays 60% after deductible
Prenatal, delivery, and postpartum
Urgent Care and Emergency Room Services
$60 copay + deductible,
Urgent Care $35 copay
then plan pays 60%
Emergency Room
$150 (waived if admitted) + $150 (waived if admitted) +
(Non-emergency use of the ER is NOT
deductible, then plan pays 80% deductible, then plan pays 60%
COVERED)
6
POS HEALTH PLAN
POSC Plan Services In-Network Plan Benefits Out-of-Network Plan Benefits
Inpatient Services: Piedmont Athens Regional and St. Mary’s
Daily room, board, and general nursing
at semi-private room rate; ICU/CU;
other medically necessary hospital Plan pays 80% after deductible Plan pays 60% after deductible
charges such as diagnostic x-ray and
lab services; newborn nursery care
Physician services: Plan pays 100% after deductible Plan pays 60% after deductible
Surgeon, Anesthesiologist, radiologist, pathologist
Outpatient Services
Plan pays 80% after $100 copay +
Surgery facility/hospital charges Plan pays 60% after deductible
deductible
Diagnostic x-ray and lab services Plan pays 80% after deductible Plan pays 60% after deductible
Physician services: Plan pays 100% after deductible Plan pays 60% after deductible
Surgeon, Anesthesiologist, radiologist, pathologist
Mental Health/Substance Abuse Services: Services must be authorized by calling 800-292-2879
Inpatient , facility fee Plan pays 80% after deductible
Plan pays 60% after deductible
Inpatient, physician fee Plan pays 100% after deductible
Partial hospitalization facility fee Plan pays 80% after deductible
Plan pays 60% after deductible
Partial hospitalization physician fee Plan pays 100% after deductible
Intensive outpatient program, facility fee Plan pays 80% after deductible
Intensive outpatient program, physician fee Plan pays 100% after deductible Plan pays 60% after deductible
Professional outpatient services $30 copay
Other Services
LiveHealth Online $10 copay $10 copay
Ambulance (ground) Plan pays 100% Plan pays 100%
(when medically necessary) Not subject to deductible Not subject to deductible
Prescription Drugs
Prescription drugs Per prescription; 30-day supply Per prescription; 30-day supply
Retail Generic Drug Tier 1 20% coinsurance Plan pays 60% after deductible
Retail Brand Name Drug Tier 2 30% coinsurance Plan pays 60% after deductible
Retail Non-Preferred Drug Tier 3 30% coinsurance Plan pays 60% after deductible
Retail Out-Of-Pocket Maximum $100 maximum per prescription N/A
Mail Order Maintenance Drugs Per prescription; 90-day supply
Generic Drug Tier 1 20% coinsurance Not Covered
Brand Name Drug Tier 2 30% coinsurance Not Covered
Non-Preferred Drug Tier 3 30% coinsurance Not Covered
Mail-Order Out-Of-Pocket Maximum $200 maximum per prescription N/A
To receive maximum coverage, have your prescriptions written by a network physician and filled at one of the pharmacies in the Anthem network. These include
certain local independent pharmacies, as well as many national chain pharmacies: Bi-Lo, CVS, Ingles, Kmart, Kroger, Publix, Walgreens, Target, Wal-Mart, and
Winn-Dixie/Save-Rite. Specialty drugs can only be obtained from a Specialty Pharmacy.
NOTE: Deductibles and maximum out-of-pocket amounts accumulate on a calendar year basis (January - December)
The information in this material is intended to provide information only. It is not intended, and should not be taken, as a statement of legal rights and
responsibilities. While every effort has been made to ensure the accuracy of information included herein, discrepancies or errors are possible. In the case of a
discrepancy between this document and the Summary Plan Documents, ordinances, and policies governing benefits adopted by the Mayor and Commission, the
official plan documents, ordinances, and policies will prevail. The Summary Plan Documents, ordinances, and policies on which the information in this document is
based are subject to change or termination at any time by action of the Mayor and Commission.
7
CHS HEALTH PLANS
Anthem Blue Cross: Consumer Healthy Solutions Plans (CHS Select) and
(CHS Value) with HSA
The CHS plans provide you with a health plan option that offers a lower premium in exchange for a greater portion of
the initial cost-share from you, with an opportunity to open a Health Savings Account (HSA) that you can use to save for
and spend on future health care costs.
Deductibles, Coinsurance &
In-Network Plan Benefits Out-of-Network Plan Benefits
Maximums
Calendar Year Deductible, by plan CHS Select CHS Value CHS Select CHS Value
-Individual $1,750 $4,000 $3,500 $8,000
-Family $3,500 $8,000 $7,000 $16,000
ACCGov HSA Contribution A semi-annual employer enrollment contribution of: *
-Individual $125
-Family $250
Plan pays 80% after deductible Plan pays 60% after deductible
Coinsurance
Member pays 20% after deductible Member pays 40% after deductible
Lifetime Maximum Benefit Unlimited Unlimited
Out-of-Pocket Calendar Year Maximum* CHS Select CHS Value CHS Select CHS Value
-Individual Includes deductible Includes deductible Includes deductible Includes deductible
-Family $4,750 $6,450 $9,500 $12,900
$9,500 $12,900 $19,000 $25,800
All family members covered under the Plan contribute toward the total Family deductible and Out-of-pocket maximum. The most any one family
member contributes is the Individual amount. Once the Family amount is satisfied, there is no further accumulation for any family members. Non-
covered items do not apply to the out-of-pocket maximums. Deductible and Out-of-pocket amounts are accumulated separately for in-network
and out-of-network services.
CHS_S and CHS_V Plan Services In-Network Plan Benefits Out-of-Network Plan Benefits
Office Visits: Preventive Care
Well-child care and immunizations,
Annual wellness exam
Plan pays 100%
Annual GYN exam Plan pays 60% after deductible
Not subject to deductible
Annual mammogram
Prostate screening
Illness or Injury
Physician office visit Plan pays 80% after deductible Plan pays 60% after deductible
Includes lab, radiology, and office surgery
Specialist office visit and 2nd surgical
Plan pays 80% after deductible Plan pays 60% after deductible
opinion
Maternity services Plan pays 80% after deductible Plan pays 60% after deductible
Prenatal, delivery, and postpartum
Urgent Care and Emergency Room Services
Urgent Care Plan pays 80% after deductible Plan pays 60% after deductible
Emergency Room Plan pays 80% after deductible Plan pays 80% after deductible
(Non-emergency use of the ER is NOT COVERED)
8
CHS HEALTH PLANS
CHS_S and CHS_V Plans Services In-Network Plan Benefits Out-of-Network Plan Benefits
Inpatient Services: Piedmont Athens Regional and St. Mary’s
Daily room, board, and general nursing
at semi-private room rate; ICU/CU;
other medically necessary hospital Plan pays 80% after deductible Plan pays 60% after deductible
charges such as diagnostic x-ray and
lab services; newborn nursery care
Physician services: Plan pays 80% after deductible Plan pays 60% after deductible
Surgeon, Anesthesiologist, radiologist, pathologist
Outpatient Services
Surgery facility/hospital charges Plan pays 80% after deductible Plan pays 60% after deductible
Diagnostic x-ray and lab services Plan pays 80% after deductible Plan pays 60% after deductible
Physician services: Plan pays 80% after deductible Plan pays 60% after deductible
Surgeon, Anesthesiologist, radiologist, pathologist
Mental Health/Substance Abuse Services: Services must be authorized by calling 800-292-2879
Inpatient , facility fee Plan pays 80% after deductible
Plan pays 60% after deductible
Inpatient, physician fee Plan pays 80% after deductible
Partial hospitalization facility fee Plan pays 80% after deductible
Plan pays 60% after deductible
Partial hospitalization physician fee Plan pays 80% after deductible
Intensive outpatient program, facility fee Plan pays 80% after deductible
Intensive outpatient program, physician fee Plan pays 80% after deductible Plan pays 60% after deductible
Professional outpatient services Plan pays 80% after deductible
Other Services
LiveHealth Online Plan pays 80% after deductible Plan pays 80% after deductible
Ambulance (ground)
Plan pays 80% after deductible Plan pays 80% after deductible
(when medically necessary)
Prescription Drugs
Prescription drugs Per prescription; 30-day supply Per prescription; 30-day supply
Retail Generic Drug Tier 1 Plan pays 80% after deductible Plan pays 60% after deductible
Retail Brand Name Drug Tier 2 Plan pays 80% after deductible Plan pays 60% after deductible
Retail Non-Preferred Drug Tier 3 Plan pays 80% after deductible Plan pays 60% after deductible
Mail Order Maintenance Drugs Per prescription; 90-day supply
Generic Drug Tier 1 Plan pays 80% after deductible Not Covered
Brand Name Drug Tier 2 Plan pays 80% after deductible Not Covered
Non-Preferred Drug Tier 3 Not Covered Not Covered
To receive maximum coverage, have your prescriptions written by a network physician and filled at one of the pharmacies in the Anthem network.
These include certain local independent pharmacies, as well as many national chain pharmacies: Bi-Lo, CVS, Ingles, Kmart, Kroger, Publix,
Walgreens, Target, Wal-Mart, and Winn-Dixie/Save-Rite. Specialty drugs can only be obtained from a Specialty Pharmacy.
NOTE: Deductibles and maximum out-of-pocket amounts accumulate on a calendar year basis (January - December)
For full details about our plans, please refer to the Summary Plan Documents, which can be obtained from the Human Resources Department or
online at www.ACCGov.com/intranet
9
DENTAL INSURANCE
Delta Dental Plan
ACCGov’s dental insurance is a voluntary benefit paid 100% by the employee. Delta Dental’s Dentist Program is a
Dental Preferred Provider Organization (DPPO) plan. You have access to thousands of participating general dentists and
specialists nationwide, and by using an In-network provider you will maximize your plan benefits and reduce your out-of-
pocket costs. You have the freedom to visit an out-of-network dentist of your choosing. If you choose a nonparticipating
dentist, you will be responsible for any difference between the contracted dental service fee and the plan’s approved
Reasonable and Customary (R&C) rate. If you receive services from a participating PPO dentist, you will only be
responsible for the PPO (in-network) fee. (See table below for fees).
Visit www.deltadentalins.com to track your claim status, check benefits, order ID cards, locate a dentist, or request a
pre-treatment estimate to obtain information about potential out-of-pocket expenses for services, compare average
dental rates in your area, and more. You can find fun and interactive tools and games for kids under the Just For Kids
link or www.MySmilesKids.com. For people on the go, download the mobile app from the App Store or Google Play to
find a dentist, view your ID card, review claims, and much more.
Call 800-521-2651 for more information.
Primary enrollee, spouse, and eligible dependent children
ELIGIBILITY
to the end of the month dependent turns age 26
Deductibles $50 per person / $150 per family each calendar year
Deductibles waived for Diagnostic and Preventive
(D & P) and Orthodontics Yes
Maximums $1,200 per person each calendar year
D & P counts toward maximum Yes
Basic Benefits Major Benefits Prosthodontics Orthodontics
Waiting Period(s)
None None None 12 Months
Benefits and Covered Services* Delta Dental PPO dentists Non-Delta Dental PPO dentists
Diagnostic & Preventive Services (D & P) 100% 100%
Exams, cleanings and bitewing x-rays
Basic Services
Fillings, full mouth x-rays, simple tooth extractions 80% 80%
and sealants
Periodontics (gum treatment) 80% 80%
Covered Under Basic Services
Periodontal Surgery 50% 50%
Endodontics (root canals) 50% 50%
Covered Under Major Services
Oral Surgery 50% 50%
Covered Under Major Services
Major Services 50% 50%
Crowns, inlays, onlays and cast restorations
Prosthodontics 50% 50%
Bridges, dentures and implants
Orthodontic Benefits 50% 50%
Dependent children only
Orthodontic Maximums $ 1,200 Lifetime $ 1,200 Lifetime
10VISION INSURANCE
Blue View Vision Plan
ACCGov provides group vision coverage as a voluntary benefit, paid 100% by the employee. The Anthem Blue View
Vision plan can offset the cost of exams, frames and lenses. For a complete list of network providers, please visit
www.Anthem.com.
Note: You cannot elect contact lenses AND glasses in the same plan year.
BLUE VIEW VISION PLAN
In-Network Provider Out-of-Network
Frequency/ Amount
Benefits Copay/ De- Copay/
Coverage Amount Coverage Amount Allowed
ductible Deductible
Routine Eye Exam $10 Paid in full N/A $30 Allowance 1 per calendar year
Contact Fitting Exam Up to $55 + $10 eye exam N/A $30 Allowance 1 per calendar year
Single Vision Lenses (copay) $25 Paid in full N/A $25 Allowance 1 per calendar year
Bifocal Lenses (copay) $25 Paid in full N/A $40 Allowance 1 per calendar year
Trifocal Lenses (copay) $25 Paid in full N/A $55 Allowance 1 per calendar year
Lenticular Lenses N/A 20% discount N/A N/A 1 per calendar year
$100 Allowance
Frames $0 N/A $45 Allowance only 1 per 24 months
+ 20% off balance
Elective Contact Lenses $115 Allowance
$0 N/A $105 Allowance only 1 per calendar year
Conventional Lenses + 15% off balance
$115 Allowance
Elective Contact Lenses
$0 no additional N/A $105 Allowance only 1 per calendar year
Disposable Lenses
discount
Medically Necessary
$0 Paid in full N/A $210 Allowance 1 per calendar year
Contact Lenses
Standard Progressive
$65 + copay Balance paid in full N/A $40 Allowance 1 per calendar year
Lenses
Premium Progressive
Lenses $91 + copay
Tier 1 $97 + copay Balance paid in full N/A $40 Allowance 1 per calendar year
Tier 2 $103 +
Tier 3 copay
Standard Polycarbonate
For children (HEALTH INSURANCE SURCHARGES
Tobacco/Nicotine Surcharge Spousal/Domestic Partner
If you are a tobacco/nicotine user, you will be charged a
$35.00 surcharge per bi-weekly pay check ($75.00 per
Surcharge
If your spouse (or domestic partner (DP)) is enrolled in
month) toward your health insurance election. Please
an ACCGov Health Insurance plan, you may be subject to
note, the surcharge applies to the employee ONLY, not
a $35.00 surcharge per biweekly pay check ($75.00 per
spouse or dependent.
month). The Spousal/DP surcharge will only apply to
Tobacco Status Affidavit employees whose spouse/DP has access to their own
employer sponsored health coverage, but has declined
During Open Enrollment, all employees who enroll in an
their employer’s health coverage and enrolled in an
ACCGov health insurance plan are required to complete
ACCGov plan in its place. (NOTE: The Marketplace,
an online Tobacco Status Affidavit regarding their
Tricare, Medicare, and Medicaid are not considered other
tobacco/nicotine status.
employer sponsored health coverage.)
Non-tobacco/Nicotine Users: Employees who certify that
they do not use tobacco or nicotine products will only Spousal/Domestic Partner
be charged the base rate medical insurance premium.
However, if employees who have declared themselves to
Surcharge Affidavit
At the time of online benefit enrollment, employees who
be tobacco/nicotine-free use tobacco/nicotine at any time,
elect spousal/DP coverage will be asked to certify their
they must immediately complete a new affidavit to change
spouse/DP’s access to an employer sponsored health
their status and will be charged the Tobacco Surcharge.
plan. The surcharge will apply as stated above. Otherwise,
This does NOT apply to any covered dependents. Only
only the base rate medical insurance premium will be
employees must certify their tobacco status.
charged. If this status changes at anytime throughout the
plan year, the employee must immediately complete a
new affidavit.
Falsifying or failing to report one’s tobacco/nicotine status and/or spousal/DP health coverage will result in disciplinary action up to and
including termination of employment. In addition, an employee who willingly makes a false or fraudulent statement could be subject to insurance
fraud which carries a penalty of a $1,000 fine, 5-years imprisonment, or both pursuant to O.C.G.A. Section 16-10 –20. Employees carry
the responsibility to inform the Benefits and Wellness Administrator in the Human Resources Department of any insurance status changes
throughout the plan year.
12ALIGHT HEALTHCARE ADVOCATE
Your FREE Healthcare Advocate
The Unified Government of Athens-Clarke County is excited to continue this
excellent benefit at NO COST to ACCGov employees. Alight, formerly known
as Compass, works to provide you with Professional Healthcare Advocates
called Health Pros who will help you be smart healthcare consumers and
save you money!
Understand Insurance Benefits — Receive guidance selecting a
healthcare plan and understanding benefits throughout the year.
Find a Great Doctor — Find the best doctors, dentists and eye care
professionals in your area who meet your personal preferences and
healthcare needs.
Pay Less for Prescriptions — Let Alight compare medication prices
and explore lower-cost options for you.
Save Money on Medical Care — Get price comparisons before
receiving care. Depending on the doctor, hospital or facility, costs can
vary by hundreds or thousands of dollars — even in-network.
Get Help with Medical Bills — Have your medical bills reviewed to
make sure you are not overcharged.
Contact Asha Nelluvelil, the Health Pro dedicated to ACCGov, at
800- 513- 1667 ext. 6619 or email asha.nelluvelil@alight.com.
13WELLNESS REWARDS
ALL FULL-TIME EMPLOYEES are eligible to 2. If you did not participate in the March 2020 ACC
Wellness on-site screening, have your doctor
earn up to $700 annually in rewards for submit the ACC Well Physician Form: either make
logging completed healthy activities! PLUS an appointment with your personal physician to
receive a $50 credit each month applied complete the measurements and complete/submit
to your ACCGov health insurance premium the form during your next annual wellness visit, or
have your doctor submit the Physician Form using
for completing your annual bloodwork and your results measured within the last year. Form is
biometric screening!! available for download at www.accgov.com/wellness.
Results from the on-site screening and Physician Form
Track your health and wellness activities on www. will be available to view in each employee’s personal ACC
myaccwell.com and earn up to $175.00 EACH quarter! Well account.
The ACC Well is accessible via computer or mobile device
for on-the-go activity tracking. My ACC Well
You will receive your earned rewards by the second Upon successful completion of the blood work and
paycheck following the end of the quarter. Members biometric screening, employees gain access to the ACC
without ACCGov health insurance, and those with the Well activity and rewards tracking website.
ACCGov POS plan will receive a paycheck credit. CHS plan 1. Log in to your ACC Well account at www.myaccwell.
members will receive an HSA deposit. com (First time users must activate their account by
first clicking “activate,” then using their employee
Blood Work and Biometric Screening ID without a zero at the beginning, and following
As an enrollment requirement, individuals who wish to the New Member activation steps. Contact ACC Well
utilize the ACC Well must complete the following each year: Member Services at 844-422-2935 for additional
guidance.)
1. Blood work for total cholesterol, LDL, HDL,
triglycerides, and glucose 2. Start logging your healthy activities to earn your
Wellness rewards! Activity logging tips are available
2. Biometric measures for blood pressure, weight, and www.accgov.com/wellness.
waist circumference (Measure at navel line. Please
contact the Wellness Team at WellnessTeam@accgov.
com if you have questions)
Health Risk Assessment
There are two options for completing and submitting
(HRA) Credit
If you are enrolling in an ACCGov health plan for 2021
these measures:
Open Enrollment, be sure you select a plan that includes
1. If you participated in the March 2020 ACC Wellness Wellness (e.g. CHS + Wellness). For simply completing
on-site screenings, your results have been auto- your screening, full-time employees enrolled in an ACCGov
matically submitted into your ACC Well account. health plan will receive a $23.08 credit on each bi-weekly
paycheck in 2021.
14HEALTH SAVINGS ACCOUNTS
ActWise/PNC
A Health Savings Account is a tax-advantaged medical savings account available to individuals participating in a high
deductible health plan (CHS plan). The HSA has triple tax advantages for participants: 1) The funds contributed to the
account are not subject to federal income tax 2) HSA funds, if invested, can earn interest tax free; and 3) Distributions
used for qualified medical expenses are not taxed. The HSA account is owned by the participant, not ACCGov.
*Note: the member is responsible for maintaining documentation of qualified expenses in case of IRS audit.
If you are enrolling in a CHS
plan for the first time, ACCGov
will auto-enroll you in a Health ACCGov will make bi-annual contributions into
Savings Account through your HSA in the amount of $125 for individual
ActWise/PNC. You will receive
a debit card that may be used
coverage or $250 for employee + spouse,
for convenient payment of your employee + child(ren) or family coverage for your
qualified healthcare expenses, participation in this plan.
and have the option to receive a
check book.
HSA Employee and Employer Contributions
Contribution limitations are set annually by the IRS. For 2021, the combined total annual HSA employer and employee
contribution limits are $3,600 for Employee Only coverage and $7,200 for Employee+1 or Family coverage. You can
make contributions to your HSA each year that you are eligible. The IRS allows members age 55 and over to make up to
an additional $1,000 in “catch-up” contributions. Members eligible for Medicare can NOT contribute to an HSA within
six (6) months prior to Medicare enrollment. Contributions that are not used during the plan year will roll over to the
next year. HSA funds belong to the participant and are fully portable.
IMPORTANT NOTE: You may only enroll in the HSA benefit if you enrolled in a CHS plan.
15HEALTH SAVINGS ACCOUNTS (HSA)
How to Use Your HSA
You can use your HSA debit card to pay for qualified expenses, and money will be pulled directly from your HSA, or pay
for qualified expenses out of pocket and ask to be reimbursed.
To access your account, log in at anthem.com or use the Sydney App. Under My Plan, choose Spending Accounts. You can:
• Track your claims and HSA spending • Pay your doctor or healthcare provider directly
• Request reimbursement • Check your balance
• Set up Direct Deposit • Find a doctor
Member Account Holder Fees
Charge (subject
Description of Fee Notes
to change)
Assumes that you are responsible for the monthly account
Account Maintenance $2.25
maintenance fee.
If you leave your company sponsored plan but keep your
Non-Anthem Account Maintenance $2.50
current HSA you are responsible for this monthly fee.
Monthly Investment Account Fee $2.25 $1,000 Minimum Balance (Threshold) in order to invest.
Account Closure Fee $25.00 One-time, charged to account holder.
Cash Advance Fee n/a Cash advances are not allowed with the debit card.
Check Reorder Fee n/a Bill payment options only.
Check Writing Fee n/a Bill payment options only.
Debit Card – ATM withdrawal n/a ATM withdrawals are not allowed.
Debit Card Transactions $0 Included in monthly fee.
Excess Contribution Refund $0
Deducted from account. Fee is waived if member chooses
Quarterly Statement – Paper $1.50
paperless statements.
Overdraft Fee $0
Payment Directed to Provider $0
Reimbursement to Member $0
Return Item $15.00
Stop Payment Fee $0
Teller Withdrawal n/a Not available.
16FLEXIBLE SPENDING ACCOUNTS
ActWise Medical Flexible Spending Account (FSA)
IMPORTANT NOTE: You may not enroll in the FSA benefit if you enroll in a CHS/HSA plan.
The Flexible Spending Account (FSA) benefit is a great way to reduce your taxable income by diverting pre-tax money
into a medical spending account. A debit card makes it even easier to pay for your eligible health-related, out-of-pocket
expenses. The FSA is a pre-tax deduction, which can be used to reimburse oneself for eligible, out-of-pocket health care
expenses. The purpose of the FSA is to cover most out-of-pocket expenses not covered under your medical, dental, or
vision plan. Eligible expenses, such as dental, medical, vision and prescriptions must be incurred between January 1
through December 31 in order to be considered a qualified FSA expense. The FSA follows the IRS “use-it-or-lose-it” rule,
so budget your election accordingly.
How to Use Your FSA
You can use your FSA debit card to pay for qualified expenses, and money will be pulled directly from your FSA, or pay
for qualified expenses out of pocket and ask to be reimbursed.
To access your account, log in at anthem.com or use the Sydney App. Under My Plan, choose Spending Accounts. You can:
• Track your claims and FSA spending • Pay your doctor or healthcare provider directly
• Request reimbursement • Check your balance
• Set up Direct Deposit • Find a doctor
Annual Contribution Limits Instances in Which You Will Not Be
• Minimum = $275
Required to Submit a Statement
• Maximum = $2,750 • The expense matches a specific co-payment you
have under your employer’s medical, pharmacy, or
Save Your Statements vision plan.
Please remember to keep all statements for all charges
• Recurring expenses will not result in a request for
made with your benefit card. Per IRS regulations, ActWise
documentation as long as the expense equals the
may be required to request itemized statements to verify
same amount, duration, and provider as a previously
the eligibility of purchases made with the card.
approved expense.
Verifying Your Card Purchases • In limited scenarios, your claim information may
You will receive a monthly online card activity statement be provided through an electronic file from your
any time you have new, resolved, or outstanding card insurance carrier or other provider.
transactions on your account. The card activity statement
consists of an activity summary and a return form that is
used to resolve outstanding transactions. If one or more
of your transactions requires further action, you must
submit the completed return form within the timeframe
specified. Failure to submit proper documentation will
result in the deactivation of your card. If you do not
provide acceptable documentation or repay the plan for
the ineligible transaction within the allotted timeframe,
your card will be deactivated.
Alight can help you with claim resolution!
Note: You must still save all receipts/statements for purchases made with your card, even if you believe the transactions meet the requirements
outlined above. All receipts should be retained for at least one year following the close of the plan year in which the expense is incurred.
17FLEXIBLE SPENDING ACCOUNTS
ActWise Dependent Care FSA Expense Examples:
This FSA benefit lets you use pre-tax dollars to pay for • Before and After School care
eligible employment-related dependent care expenses. • Preschool or Nursery school
It sets money aside from your paycheck before taxes
• Extended Day programs
are taken out. You can then use these funds to pay for
eligible dependent care expenses throughout the plan • Babysitter
year. You save money on expenses you’re already paying • Nanny services
for like day care and preschool. Setting aside pre-tax • Summer Day Camp
dollars means you pay fewer taxes and increase your • Elder Day Care for a qualifying individual
take-home pay.
Qualified Dependents Contributions & Income Tax Filings
The current maximum employee contribution amount set
A qualifying individual is your dependent child under the by the IRS is $5,000 per year. If you are married and file
age of 13 who lives with you for MORE than half the year, separate tax returns, the maximum amount is $2,500
or any adult you can claim as a dependent on your tax per spouse. If you are married and file a joint return,
return that is physically or mentally incapable of self-care your combined maximum election amount is $5,000.
and lives with you for MORE than half the year. The Dependent Care FSA follows the IRS “use-it-or-lose-
it” rule, so budget your election accordingly. If you elect
Qualified Expenses and contribute to Dependent Care FSA, you may not be
The care provided to your dependent must be so you (or eligible to claim a Dependent Care Credit on your income
your spouse) can work. “Work” includes actively looking tax filings. Speak with your tax advisor for further details.
for a job. Work does not include unpaid volunteer work.
CHECK OUT ANTHEM.COM FOR FAQ’S, PLAN DETAILS,
IRS REGULATIONS, CLAIM FORMS, AND ACCOUNT DETAILS!
Note: For further details about our plans, please refer to the Summary Plan Documents, which can be obtained from the Human Resources
Department or online at www.ACCGov.com.
18CRITICAL ILLNESS INSURANCE
What is Critical Illness Insurance?
When a serious illness strikes, Critical Illness Insurance can provide a lump-
sum, tax-free, cash payment that can help you with your financial needs. You
can use this coverage more than once. If you receive a full benefit payout for
a covered illness, your coverage can be continued for the remaining covered
conditions. You can use the lump sum payment however you choose (there is
no usage restriction). Critical Illness Insurance provides a financial peace of
mind in one of life’s most stressful circumstances.
Summary of Critical Illnesses
Please see policy definitions for complete details about these covered
conditions
COVERED CONDITIONS:
• Heart attack - Blindness - Major organ failure - End-stage renal (kidney)
failure - Occupational HIV - Coronary artery bypass surgery; pays 25% of
lump sum benefit - Benign brain tumor
COVERED CONDITIONS WITH TIME LIMITATIONS:
• Stroke — Evidence of persistent neurological deficits confirmed by a
neurologist at least 30 days after the event
• Coma — Coma resulting from severe traumatic brain injury lasting for a
period of 14 or more consecutive days
• Permanent paralysis — Complete and permanent loss of the use of two or
more limbs for continuous 90 days as a result of a covered accident
CANCER CONDITIONS:
• Cancer — Carcinoma in situ pays 25% of lump sum benefit
Benefit Options
You can choose to purchase Employee Coverage of $15,000 or $25,000, and
Spouse Coverage of $10,000. Child coverage is automatically added at 25%
of the Employee Benefit Amount when Employee coverage is elected. The
coverage offers a portable option if needed.
Added Wellness Benefit
With Critical Illness Insurance, there is an added benefit that will pay you
when you, or your spouse, complete your annual physical, or other health
screenings such as blood tests, stress tests, colonoscopies, chest x-rays,
mammograms, etc. (A full list of covered tests is available on the ACCGov
website.) The benefit can pay $50 per calendar year if a covered health
screening test is performed. This is a benefit to reward you for your healthy
behavior in taking the first step to prevent a critical illness in your life.
19GROUP ACCIDENT INSURANCE
What is Group Accident Insurance? Who can be covered?
Also provided by UNUM, Group Accident Insurance is just Choose the coverage that is right for you! All ACCGov full- time
one more elected benefit option offered to all full-time employees and their dependents can be covered. Dependent
ACCGov employees to maintain the high level of benefit coverage can be purchased in addition to employee coverage
expectations. Accidents can happen anytime, anywhere. for a flat payroll rate. The coverage is portable if needed.
Group Accident Insurance is protection against accident
related costs that can strain your budget. Group Accident How does it work?
Insurance pays a benefit directly to you if you have a Real-life example… With full-time jobs and active kids,
covered injury, on or off the job, and need treatment. parents have a lot of demands on their time—and their
With the continued rise in the cost of medical procedures, bank account! When one of their rowdy boys breaks
Group Accident Insurance can provide ACCGov employees something other than a window, they don’t need an injury
a financial safety net. to break the bank as well!
Examples of covered injuries and Out-of-pocket expenses from a torn ACL (knee ligament
injury) are incurred: ER Copay $150.00 + Deductible
expenses $700.00 + Coinsurance ($3,500x20%) $700.00 + Copay
(See the Schedule of Benefits at www.ACCGov.com for a for six physical therapy visits $210.00 = Total expenses
full list) $1,760.00
Nontaxable Benefit Payout from Unum: ER Visit $150.00
INJURY EXAMPLES:
+ Appliance (knee brace) $100.00 + Outpatient Surgery
Broken/fracture bones—burns—torn ligaments—tendon facility service $300.00 + Surgical Ligament tear repair
repair—lacerations—eye injuries—ruptured discs— $800.00 + Six physical therapy sessions $150.00 = Total
concussion—dental work—skin graft—dislocation Payout $1,500.00
EMERGENCY & HOSPITALIZATION: $1,760.00—$1,500.00 = $260.00 Total Out-of-pocket
Emergency room treatment—ambulance service— Expenses!!
emergency treatment at urgent care—ICU admission—
medical imaging—outpatient surgery facility—doctor office
visit—hospitalization—occupational therapy—speech
therapy—chiropractic visit—physical therapy—pain
management
TREATMENT & OTHER SERVICES:
Surgery—physician follow up—therapy—prosthetic device/
artificial limb—appliance—blood/plasma/platelets—travel
& lodging due to accident—rehab confinement
ACCIDENTAL DEATH & OTHER LOSSES:
Accidental death of employee/spouse/child—accidental
dismemberment—accidental loss of sight/hearing/
speech—paralysis
20INCOME PROTECTION BENEFITS
Short-Term Disability Insurance
The Unified Government of Athens-Clarke County provides you with Short-Term Disability (STD) Insurance to provide
you and your family financial security should you be unable to perform the full, essential functions of your job due to a
non-work related, temporary total disability. This benefit is provided at no cost to you. Disability is defined as a bodily
malfunction, accidental injury, complications resulting from pregnancy, or mental illness.
Eligibility for this benefit begins on the first day of the month following a full month of regular, full-time employment.
Short-Term Disability payments begin on the thirty-first (31st) workday following the onset of your illness or injury-
causing disability. While you remain eligible for Short-Term Disability, you will be paid at a rate of 60% of your base
salary (not to exceed $1,000 per biweekly pay period). Short-Term Disability may continue for a maximum of twenty-six
(26) weeks from the initial onset of the disability including 6-week elimination period. Contact HR for more information.
Long-Term Disability Income Protection Insurance
ACCGov offers voluntary long-term income protection through Unum to employees who have completed 24 months of
continuous, active, full-time employment. Employees may enroll in this plan during the Open Enrollment following the
completion of 24 months of continuous, active, full-time employment. If an employee declines coverage when first
eligible, and enrolls at a later Open Enrollment, he/she will be required to complete a Medical Insurability form.
The Long-Term Disability plan pays benefits in the event you become unable to work for more than six (6) months due to
an illness or injury. Benefit payments begin after you have satisfied the 180-day elimination period. Benefits are subject
to an application, review, and approval process by Unum. The chart below is a brief outline of the plan. Please see the
Summary Plan Document for complete plan details.
Benefit Amount 60% of Monthly Earnings
Maximum Monthly Benefit $7,000
Elimination Period 180 Days (6 months)
Benefit Duration Up to Social Security Retirement Age
Your premium is calculated based on your age and your salary. For example, if you are 41 years old and your annual
salary is $44,000, the calculation would be as follows:
$44,000 ÷ 12 = $3,667 monthly salary x rate of $0.52 (41 year old rate) = $1,907 ÷ 100 = $19.07 (monthly premium)
x 12 = $229 (annual cost) ÷ 27 pay periods = $8.48 (bi-weekly premium).
21INCOME PROTECTION BENEFITS
Long-Term Disability Income Protection Insurance (continued)
To calculate your premium based on your age and salary, use the following formula:
_______________ ÷ 12 = _______________ x _________ ÷ 100 =_______________ x 12 ÷ 26 =______________
Annual salary Monthly Salary Rate by age Monthly premium Biweekly premium
Premiums will be automatically adjusted following any salary adjustment or age bracket change!
If you declined LTD insurance when first eligible and you Monthly Rate for each $100 of
Employee Age
wish to enroll this year, you must complete an Evidence your monthly salary
of Insurability.INCOME PROTECTION BENEFITS
Dependent Life Insurance Whole Life Insurance
You may purchase Dependent Life Insurance in the Whole Life Insurance provides much more than a death
amount of $5,000, $10,000 or $15,000 for each eligible benefit—it also offers valuable “living benefits” that you
child. You may purchase Dependent Life Insurance in can use during times of need. The policy accumulates
the amount of $15,000, $25,000 or $50,000 for your cash value, has a terminal illness rider, and includes a
eligible spouse. Dependent Life Insurance coverage for Long Term Care rider. The policy can be taken with you at
a child under six (6) months of age is $1,000. When that the same cost upon employment termination. Rates are
child reaches six (6) months of age, the child is insured at age-based premiums that lock in at first enrollment.
the full amount requested.
Beneficiaries
Coverage Exclusions You are required to list your beneficiaries for your life
Service members of the National Guard or Reserves insurance benefits. You are the automatic beneficiary
are not eligible for the basic life, contributory life or for your dependent life insurance. Beneficiary changes
dependent life insurance benefit(s) while on active may be made at any time during the year. You may
duty deployment. An employee, whose spouse is active pick up a Beneficiary Designation form at the Human
military or who is also an employee of the Unified Resources Department or download one from the
Government of Athens-Clarke County, is not eligible to website at www. ACCGov.com. Beneficiaries under 18
take the dependent life insurance benefit. IMPORTANT years of age will not have immediate access to funds.
NOTE ABOUT DUAL EMPLOYMENT: Employees who are Benefits are held in an interest bearing account until the
married to another ACCGov employee may not purchase child reaches 18 years of age. Ask a Human Resources
dependent life insurance for their spouse, and only one representative for more information about setting up a
parent may select coverage for their children. trust as a beneficiary.
23INSURANCE PREMIUMS*
Unified Government of Athens-Clarke County 2021 Rate Sheet
Effective January 1, 2021
Delta Dental Rates Anthem Vision Rates
Coverage Election Biweekly Payroll Monthly Payroll Biweekly Payroll Monthly Payroll
Deduction Deduction Deduction Deduction
Employee Only $13.13 $28.45 $2.45 $5.30
Employee + Spouse $25.35 $54.92 $4.28 $9.28
Employee + Child(ren) $30.69 $66.49 $4.65 $10.07
Family $42.88 $92.91 $7.09 $15.37
Anthem Major Medical Insurance Rates
POS CONVENTIONAL PLAN (posc)
Coverage Election
Biweekly Base Rate - Monthly Base Rate -
Biweekly Base Rate Monthly Base Rate
HRA Credit* HRA Credit*
Employee Only $129.34 $280.24 $106.26 $230.24
Employee + Spouse $258.68 $560.48 $235.60 $510.48
Employee + Child(ren) $232.81 $504.43 $209.73 $454.43
Family $388.02 $840.72 $364.94 $790.72
CHS_Select WITH HSA PLAN
Coverage Election Biweekly Base Rate - Monthly Base Rate -
Biweekly Base Rate Monthly Base Rate
HRA Credit* HRA Credit*
Employee Only $98.53 $213.49 $75.45 $163.49
Employee + Spouse $197.07 $426.98 $173.99 $376.98
Employee + Child(ren) $178.15 $386.00 $155.07 $336.00
Family $291.63 $631.86 $268.55 $581.86
CHS_Value WITH HSA PLAN
Coverage Election Biweekly Base Rate - Monthly Base Rate -
Biweekly Base Rate Monthly Base Rate
HRA Credit* HRA Credit*
Employee Only $48.86 $105.87 $25.78 $55.87
Employee + Spouse $97.73 $211.74 $74.65 $161.74
Employee + Child(ren) $88.42 $191.58 $65.34 $141.58
Family $144.24 $312.51 $121.16 $262.51
IMPORTANT NOTE ABOUT HRA CREDIT AND SURCHARGES: The HRA incentive credit is equal to $23.08 per biweekly pay
period, or $50.00 per monthly pay period (not to exceed $600.00 per fiscal year). A $35.00 tobacco surcharge will be
added to the Base Rate Premiums each bi-weekly pay period for employees enrolled in a health insurance plan who use
tobacco or nicotine products. A $35.00 spousal/domestic partner surcharge will be added to the Base Rate Premiums
each bi-weekly pay period for employees enrolling their spouse/domestic partner in a health insurance plan when their
spouse/domestic partner has access to, and opts out of, their own employer sponsored health insurance plan.
*There are 26 pay periods in 2021. The total annual tobacco & spousal surcharges & HRA Wellness credits remain unchanged, but the bi-weekly
amount is being calculated based on 26 pay periods.
*Paycheck will reflect an HRA Wellness Credit of $-23.08 after you complete your Biometric Screening.
24GROUP ACCIDENT AND CRITICAL ILLNESS PREMIUMS
UNUM Group Accident Premiums by Coverage Election
Coverage Election
Biweekly Payroll Deduction Monthly Payroll Deduction
Employee Only $6.01 $13.03
Employee + Spouse $9.72 $21.07
Employee + Child(ren) $11.23 $24.33
Family $14.94 $32.37
UNUM Group Critical Illness Premiums by Coverage Election
Employee Bi-Weekly Premiums Spouse Biweekly Premiums
Non-Tobacco Tobacco Non-Tobacco Tobacco
$15K $25K $15K $25K $10K $10KLIFE INSURANCE PREMIUMS
Contributory / Supplemental Life Insurance Premiums
The Basic Life insurance benefit provided by ACCGov is equal to 2 times your annual salary + $5,000 (rounded up to
the nearest 1,000). You may increase your Contributory Life insurance during this Open Enrollment by completing an
Evidence of Insurability form. The amount of life insurance in excess of your current amount will “pend” until approved
by Unum. If the excess amount is denied, your coverage election will not change.
UNUM Contributory Life Premiums
Coverage Biweekly Monthly Coverage Biweekly Monthly
Election Premium Premium Election Premium Premium
$10,000 $1.29 $2.80 $210,000 $27.09 $58.70
$20,000 $2.58 $5.59 $220,000 $28.38 $61.49
$30,000 $3.87 $8.39 $230,000 $29.67 $64.29
$40,000 $5.16 $11.18 $240,000 $30.96 $67.08
$50,000 $6.45 $13.98 $250,000 $32.25 $69.88
$60,000 $7.74 $16.77 $260,000 $33.54 $72.67
$70,000 $9.03 $19.57 $270,000 $34.83 $75.47
$80,000 $10.32 $22.36 $280,000 $36.12 $78.26
$90,000 $11.61 $25.16 $290,000 $37.41 $81.06
$100,000 $12.90 $27.95 $300,000 $38.70 $83.85
$110,000 $14.19 $30.75 $310,000 $39.99 $86.65
$120,000 $15.48 $33.54 $320,000 $41.28 $89.44
$130,000 $16.77 $36.34 $330,000 $42.57 $92.24
$140,000 $18.06 $39.13 $340,000 $43.86 $95.03
$150,000 $19.35 $41.93 $350,000 $45.15 $97.83
$160,000 $20.64 $44.72 $360,000 $46.44 $100.62
$170,000 $21.93 $47.52 $370,000 $47.73 $103.42
$180,000 $23.22 $50.31 $380,000 $49.02 $106.21
$190,000 $24.51 $53.11 $390,000 $50.31 $109.01
$200,000 $25.80 $55.90 $400,000 $51.60 $111.80
UNUM Dependent Life Insurance Coverage
Coverage Election
Biweekly Payroll Deduction Monthly Payroll Deduction
Spouse: $15,000 $0.64 $1.38
Spouse: $25,000 $1.06 $2.30
Spouse: $50,000 $2.12 $4.60
Child(ren): $5,000 (coverage per child) $0.25 $0.55
Child(ren): $10,000 (coverage per child) $0.51 $1.10
Child(ren): $15,000 (coverage per child) $0.76 $1.65
Whole Life Insurance Premiums
Whole Life Insurance premiums are age based and can be viewed when completing your online benefit enrollment.
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